In a manuscript recently accepted to BJPsych Bulletin, released in a pre-print format, psychologist Lucy Johnstone calls for a drastic shift in the discourse surrounding wellbeing in the context of COVID-19. She writes that the conceptualization of the COVID-19 pandemic as parallel yet separate from an epidemic of “mental health” has the effect of minimizing appreciation for contextual determinants of distress. According to Johnstone:
“In the current jargon, popular in both psychology and psychiatry, we need a [re]formulation – a shift from ‘patient with illness’ to ‘person with a problem.'”
Johnstone seeks not to downplay the substantial, widespread implications of loss and uncertainty associated with COVID-19, but to reframe how we think and talk about them. Among her chief concerns is that the narrative of a “mental health crisis” prevalent in the media misrepresents the existing research. She cites one sizeable, longitudinal survey study suggesting immediate distress related to disease precautions followed by trend indicating longer-term coping and resilience.
“COVID-19 and its consequences are not hitting us all equally. In ordinary language, people with more to be exhausted, depressed, and anxious about are feeling more exhausted, depressed, and anxious. However, the general picture is, in the words of the researchers, of a population which is ‘largely resilient.'”
Survey results also indicated that those experiencing sustained distress were more likely to have been challenged by circumstantial disadvantages such as pre-existing conditions, exposure to the virus, families to manage, etc. The water was already murky in the pursuit of disentangling clinically significant distress from circumstantial demands of a person. The spread of COVID-19 has further complicated matters.
“People who have lost their jobs are likely to feel desperate, but we don’t have to describe this as ‘clinical depression’ and prescribe drugs for it. Those with backgrounds of severe trauma may find that their worst memories are being triggered, but we don’t have to describe this as a relapse of their ‘borderline personality disorder.’ The economic recession that will follow the pandemic may lead to as many suicides as austerity measures did, but we don’t have to say that ‘mental illness’ caused these deaths.”
Johnstone notes that behaviors that might have historically been considered abnormal may be protective in the context of a pandemic. Although constant hand washing and avoidance of social circumstances may have traditionally been considered problematic, these are now (in some settings) acceptable – encouraged, even. In the absence of biomarkers to indicate most psychological disorders, diagnostic determinations can be tenuous. The pandemic has made it all the more challenging to tease out abnormal behavior but may also be inspiring fresh ways of thinking about “mental health.”
Some of the language used in public service announcements surrounding anxiety, loneliness, and feelings related to depression during the pandemic – including those acknowledging the idea that distress is expected during such a time – puts the onus on people to “speak up” about mental health and “seek help.” A snorkel in a tidal wave. In relation to COVID-19, a wave primarily impacting people with other vulnerabilities, Johnstone adds:
“Not a single new research study is needed to confirm that being poor, jobless, isolated, ill, and bereaved makes people unhappy, or to work out the appropriate remedies.”
Is prolonged distress indicative of “illness” when experienced amidst isolation, food and housing insecurity, and medical risk? If the pandemic-related “tsunami of mental illness” anticipated by some psychologists and psychiatrists is realized only among those most proximally impacted by COVID-19 and precautions, is psychology the ideal entry point for intervention? Johnstone believes the best options in alleviating distress include initiatives in which “participation, community, trust, and connection [are] valued over status, individualism, and competition.”, as advised by Psychologists for Social Change.
Johnstone offers that as an alternative to thinking about sustained psychological distress as something wrong with a person, it may be more useful to focus on what has happened to a person – understanding distress and pain as “meaningful patterns of responses to threats.” She suggests that one of the risks of attributing distress to mental illness is the pattern of then compartmentalizing feelings that one may ultimately have benefitted from staying better connected to.
Conflating loss of hope, for example, associated with job loss, stress surrounding tasks required of raising children in the context of COVID-19 precautions, and lack of social opportunity with psychological disorder may be detrimental to wellbeing. Rehabilitating community systems and creating new programming when not to support the overall quality of life could set the wheels in motion for healing that, Johnstone believes, could far surpass the therapeutic benefits of available psychological treatment options.
Johnstone, L. (2020). Does coronavirus pose a challenge to the diagnoses of anxiety and depression?: A psychologist’s view. BJPsych Bulletin, 1-10. DOI:10.1192/bjb.2020.101 (Link)